CONCUSSION Objectives MANAGEMENT IN THE ADOLESCENT ATHLETE · Neuro-Opthalmology /Optometry Psychology/Psychiatry Cognitive Therapy . Concussion Management in the Adolescent Athlete

Concussion Management in the

Adolescent Athlete

2/10/12

This information is the property of Anne

Mucha & Sean Learish and should not be

copied or otherwise used without express

written permission. 1

CONCUSSION

MANAGEMENT IN

THE ADOLESCENT

ATHLETE Anne Mucha, DPT, MS, NCS

Sean Learish, MPT Centers for Rehab Services,

University of Pittsburgh Medical Center

Sports Concussion Program

Combined Section Meeting 2012

TO DO:

1.

2.

3.

4.

5.

6.

Objectives

Describe the pathophysiology, signs and symptoms of

concussion

Recognize factors contributing to prognosis and

outcome following concussion in young athletes

Describe negative outcomes related to concussion

Identify management principles for rehabilitation of the

concussed adolescent athlete

Recognize the role of physical therapy in the

multidisciplinary management of concussion

Apply the principles of exertional rehabilitation to

concussion management in adolescents

Concussion: Spotlight on the

Professional Athlete The Reality:

The Concussion “Epidemic”

Estimated 1.6-3.8 million sports and recreation concussive injuries occur annually in US (CDC

Toolkit for Physicians, 2008)

Between 1997-2007 the number of ED visits for 14-19 year olds for concussion TRIPLED!

> 40% of Concussions dx’d in ED occur in children/adolescents between 5-19 yo.

30-58% of ED-dx’d concussions due to SPORTS

(Bakhos 2010) (Meehan 2010)

Lowest: Baseball (.05 - .06)

Cheerleading (.06)

Highest: Football (.47-.6)

Girls’ soccer (.32.-.35)

Boys’ Lacrosse (.3)

Girls’ Lacrosse (.2)

Which sports have highest risk? Incidence Rates for High School Sports

(based on 1000 athletic exposures) APPROX 10% OF

ALL HIGH

SCHOOL

SPORTS

INJURIES ARE

CONCUSSIONS

Trends: Concussion rate has steadily increased over time

Girls – nearly 2x risk in similar sports

(Lincoln 2011; Gessel 2007)


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Participation Rates (non contact sports omitted)

1. Football (3X)

2. Boys’ Basketball

3. Girls’ Basketball

4. Baseball

5. Softball

6. Boys’ Soccer

7. Boys’ Wrestling

8. Girls’ Volleyball

9. Girls’ Soccer

10. Girls’ Field Hockey

Sports w/ Highest

Incidence Rates

Football

Girls’ soccer

Boys’ Lacrosse

Girls’ Lacrosse

35 million kids

10

# 10. Girls field

Concussion: CDC Definition A complex pathophysiologic process affecting

the brain, induced by traumatic biomechanical forces secondary to direct or indirect forces to the head.

Caused by a jolt to the head or body that disrupts the function of the brain.

Typically associated with normal structural neuroimaging findings (ie CT scan, MRI).

Results in a constellation of physical, cognitive, emotional or sleep-related symptoms that may or may not involve a loss of consciousness (LOC).

Duration of symptoms is highly variable and may last from several minutes to days, weeks, months, or longer in some cases.

Centers for Disease Control, 2007

What Causes a Concussion? Mechanism of Injury

Blow to head or body, direct impact not necessary

Acceleration/Deceleration

Rotational Forces

Frequently no LOC

Pathophysiology

Concussion is a metabolic, rather than structural, brain injury

Giza CC, Hovda

DA. The

Neurometabolic

Cascade of

Concussion. J Athl

Train. Sep

2001;36(3):228-235.

Pathophysiology

Neurometabolic Cascade

↑ ENERGY DEMAND + ↓ BLOOD SUPPLY

=

METABOLIC CRISIS


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What about kids?

Pediatric concussion studies support this

model of functional, rather than structural,

injury (Maugans 2011)

Post Concussion CBF regulation may be

more variable in pediatrics

Certain pathology seen only in pediatrics:

eg. Second Impact Syndrome

Children are not Small Adults!!

Cases of

severely

reduced

CBF

(hypoxia)

and

of

hyperemia

both

observed.

Differences between adult and

pediatric heads:

Smaller head size compared w/ body

Brain water content

Vasculature

Myelination

Shape of skull

Cervical muscle strength (Meehan 2010)

INSERT A

PICTURE

Post-Injury Differences

Differences in glutamate receptor

expression

Increased vulnerability to oxidative

stress

Differences in dopaminergic activity

Vascular responses to injury

Susceptibility of glutamate receptors

Susceptibility to Repeat TBI in Young?

Pre-adolescent rats subjected to 2 concussions one day apart. Repeat mTBI rats had:

> axonal damage

↑’d memory impairment in novel task

↑’d astrocyte reactivity

↑’d mortality

1st 24 h post injury may be a critical time period

From: Prins ML, Hales A, Reger M, Giza CC, Hovda

DA. Repeat traumatic brain injury in the juvenile rat

is associated with increased axonal injury and

cognitive impairments. Dev Neurosci. 2010;32(5-

6):510-518.

Introduced into Congress, January 26, 2011

Findings after Concussion:


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ER Management of Children w/ mTBI

69% of children presenting to ED w/ concussions receive scans

< 10% have abnormalities

Radiation exposure: ↑’d risk of leukemia/solid organ tumors in pediatric vs adult pts exposed to CT

Clinical prediction rules based on: GCS < 14

Altered mental status

Signs of skull fx

Severe mechanism of injury

LOC or vomiting

Severe HA

Abnormal behavior

Short sequence MRI may be better alternative (Klig 2010), Meehan 2010)

Early symptoms following concussion (Sports-Related)

1. Headache (71%)

2. Feeling slowed down (58%)

3. Difficulty concentrating (57%)

4. Dizziness (55%)

5. Fogginess (53%)

6. Fatigue (50%)

7. Visual blurring/double vision (49%)

8. Light sensitivity (47%)

9. Memory dysfunction (43%)

10. Balance problems (43%) (Lovell 2004)

Cognitive Symptoms

• “Fogginess”

• Difficulty concentrating • Memory deficits

• Cognitive Fatigue

Somatic Symptoms

• Headaches • Dizziness

• Nausea • Light/Sound

Sensitivity

Mood Disruption

• Irritability

• Feeling sad • Anxiety

Sleep Alterations

• Difficulty falling asleep

• Fragmented sleep

• Too much/too little sleep

Symptom Clusters

following Sports

Concussion

(Lovell et al 2006)

SOMATIC also

includes:

Blurred vision,

motion sensitivity,

poor balance,

neck pain

Post-Concussion Scale (Lovell 2006)

Post-Concussion Symptom Inventory (Gioia 2008)

Graded Symptom Checklist (Guskiewicz 2004)

Rivermead Post-Concussion Symptoms

Questionnaire (King 1995)

The problem with Symptom Checklists:

Under-reporting & magnification are common (McCrea 2004, Williamson 2006)

Symptom Checklists in

Pediatric Concussion

Symptom Reporting in Children

Psychometric evidence for the use of concussion

symptom scales is stronger for adolescents (ages 13-22

years) than for younger athletes (ages 5-12 years) (Gioia 2009)

Children (< 10 yo) may report concussion symptoms

differently from adults

Age-appropriate symptom checklists are recommended

after a suspected concussion

(McCrory 2009)

Neurocognitive Assessment

Hallmark of management of post concussive

patient (Aubry 2002, McCrory 2005, McCrory 2009)

Traditional: paper-pencil testing

Computerized models often used

Most useful when patient has baseline testing

for comparison post concussion

Not recommended as “stand alone” measure,

however (Randolph 2005)


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Computerized Assessment Measures

Sports/General Population:

• ImPACT (Immediate Post-Concussion Assessment

and Cognitive Testing)

http://www.impacttest.com/

• CogState Sport

www.cogstate.com provides normative data,

descriptions

• Headminders CRI (Concussion Resolution Index)

www.headminder.com/site/cri

Military:

• Automated Neuropsychological Assessment Metrics

(ANAM)

Concussion Assessment:

Balance, Vestibular & Visual

System Findings

Very common acutely and sub-acutely following concussion (Geurts 1996; Guskiewicz 1997; Guskiewicz 2000)

Often related to abnormalities in Sensory Organization

It appears that, in particular, the ability to utilize and process vestibular information needed for postural control may be affected in concussed athletes (Peterson 2003; Guskiewicz 2001)

Impaired Postural Control Dynamic Posturography Sensory Organization Test (Nashner, 1982)

www.jneuroengrehab.com/content/figures/1743-0003-4-42-1-l.jpg

www.therapy-equipment.com/lem-images/SMA_0007.jpg

Clinical Test for Sensory Interaction in

Balance

CTSIB

6 Conditions

Firm / Foam Surface

Eyes Open

Eyes Closed

Dome

30 seconds

2 or more falls/3 trials

Shumway-Cook A., Horak F. 1986

Balance Error Scoring System

BESS Test (6 items)

3 Postures Standing feet

together

Single-limb Stance

Tandem Stance

Firm / Foam Surface

Eyes Closed

20 seconds

Scored by number of errors committed

Guskiewicz, K. University of North Carolina Sports Medicine Research Laboratory

http://www.impacttest.com/

http://www.cogstate.com/

http://www.headminder.com/site/cri


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Balance Measures

Self Report (subjective)

Activity-Specific Balance

Confidence Scale (ABC)

Falls Efficacy Scale (FES)

Functional Outcome

Measures

Dynamic Gait Index

Functional Gait

Assessment

HiMAT

**Dual Cognitive Task

paradigms

Five Time Sit to Stand

TUG

Post Concussive Dizziness: Present in 23% to 81% of cases in the first days

after injury.23-27 (Griffiths 1979; Kisilevski 2001; Maskell 2006;

Maskell 2007, Terrio 2009)

In blast-related mTBI, most common post-injury

symptom (Hoffer 2010)

Dizziness was the sole ON FIELD factor

predictive of protracted (> 21 days) time to

recovery (Lau 2011)

Common symptom in persistent post-concussion

syndrome, with prevalence as high as 32.5% at

5 years (Masson 1996)

Inner Ear

Benign Paroxysmal

Positional Vertigo

(BPPV)

Labyrinthine

Concussion

Perilymphatic Fistula

Central/Brain

Post traumatic migraine

Brainstem concussion

Autonomic dysregulation/

postural hypotension

Oculomotor abnormalities

Seizures (rare with mTBI)

Etiology of Dizziness in Concussion (Adapted from Furman 2010)

Cervicogenic Dizziness

Pursuits

Saccades

Vergence/Accomodation

Alignment

Gaze Holding

Visual Fields

(Kapoor 2002; Ciuffreda 2007)

Visual/Ocular Motor

Abnormalities often seen in:

Blurred vision

Double vision

Jumping images (oscillopsia)

Eye strain

Dizziness

Oculomotor Disturbances –

subjective complaints:

Intervention is often helpful! Ciuffreda 2008

Management of the Post Concussive

Patient: Multidisciplinary Team

Core Medical Team Academic Team:

Neuropsychology

MD (with concussion

background/training)

Physical Therapy

(Vestibular and/or

Exertional)

Athletic Trainer

School Nurse

Guidance Counselors

Teachers

Coaches

Athletic Director

Parents/family

WHEN NEEDED:

Neuro-Otology

Neuro-Opthalmology /Optometry

Psychology/Psychiatry

Cognitive Therapy


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Individual Recovery From Sports MTBI: How Long Does it Take?

0

10

20

30

40

50

60

70

80

90

100

1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35 37 38 40+

All Athletes No Previous Concussions 1 or More Previous Concussions

N=134 Male Football Athletes

WEEK 1 WEEK 2 WEEK 3 WEEK 4 WEEK 5

40% RECOVERED

60% RECOVERED

80% RECOVERED

Collins et al., 2006, Neurosurgery

FACTORS RELATED TO OUTCOME

Constitutional Factors:

Age

Professional athletes - 1

day

College athletes - 2-7 days

High school athletes - 7-14

days

Gender Females have higher risk of

sustaining concussion

Longer recovery time

(Broshek 2005, Covassin 2011,

Dischingere 2009, Morrison 2004,)

Migraines:

Athletes with post

traumatic migraines had

significantly lower

cognitive performance

compared with those with

no headache or even

those with non

migrainous headaches

Mihalik et al., 2005

Sometimes, you gotta dig!

Repetitive Injury:

History of 3 or more concussions is associated with

subjective symptoms, and poorer cognitive test

performance

Athletes with ≥ 3 concussions may be at greater

risk for future concussion Iverson et al., 2004; Guskiewicz et al.,2003

Other Constitutional Factors:

Learning disabilities (Collins 1999)

Pre-existing mood disorders ?

FACTORS RELATED TO OUTCOME:

Acute/On-Field Symptoms:


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Amnesia: Predictive of ability to detect quick recovery

(≤ 3 d)

Retrograde vs Anterograde (post traumatic)

Presence of amnesia was most predictive of postinjury difficulties at 3d after injury

Those athletes with high degree of symptoms and cognitive deficits

10x more likely to have had any degree of retrograde amnesia

4x more likely to have had any degree of anterograde amnesia

Brief LOC was NOT related to quick recovery (Collins et al., 2003)

?

Are there any

On-Field

Symptoms that

predict

protracted

recovery?

30 days 5 days

7 days

10 days 14 days

81 days

Recovery for Concussed Dogs

Determining Which On-Field Signs/Symptoms Were

Most Predictive of Protracted Recovery

Variables Wald χ2

OR p 95% CI for OR

Dizziness 5.44 6.34 0.02 1.34 -29.91

LOC 2.53 0.27 0.11 0.54 – 1.35

Vomiting 1.45 0.42 0.23 0.10 – 1.72

Direct LR with 3 predictors: χ2 (3, 94)= 11.77, p= .008 Predictors reliably distinguish between rapid and protracted recovery groups

Lau et al 2011

FACTORS RELATED TO OUTCOME:

Post Injury Factors

Fogginess: May be associated with a

more severe course and protracted recovery

“Foggy” athletes vs non-foggy athletes:

Slower reaction time

Attenuated memory performance

Slower processing speed

Significantly higher number of other post-concussion symptoms

(Iverson 2004)

NeuroCognitive Testing:

Early (< 3 d) deficits in reaction time and

visual memory (on ImPACT test)

predictive of > 10 day recovery course

Athletes w/ deficits in 3 out of 4 global

areas of ImPACT test: 94.6% likely to

require at least 10 days until recover (Iverson 2007)

N =114 High School Football Players


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Exertion:

Student athletes who engaged in high

levels of activity in the weeks following

concussion had increased symptoms and

worsened neurocognitive data

They also had significantly longer recovery

time

Majerske et al., 2008

Cognitive Symptoms

• “Fogginess” • Difficulty concentrating

• Memory deficits

• Cognitive Fatigue

Somatic Symptoms

• Headaches

• Dizziness

• Nausea • Light/Sound

Sensitivity

Mood Disruption

• Irritability

• Feeling sad • Anxiety

Sleep Alterations

• Difficulty falling asleep

• Fragmented sleep

• Too much/too little sleep

What

happens

when

symptoms

don’t go

away with

rest

alone?

(Lovell et al 2006)

Medications

Activity

School

Rehab

Management of Concussion Headache Management:

Most common post concussive symptom (71% in sports-related concussion)

Types based on etiology: Cognitive-Fatigue

Migraine

Musculoskeletal/Cervicogenic

Medication Induced (Bigal 2004)

Combination OTC meds

Opiods

Triptans

Cognitive Fatigue Headaches Scenarios:

High school junior sustains concussion. Returns to school asymptomatic, but routinely experiences headaches by mid-morning. Cannot eat lunch in cafeteria. Frequently in nurse’s

office and often leaves school early due to headaches. 15 year old student experiences concussion. Has no symptoms at

rest, but notices headaches with climbing stairs and physical activity.

Potential Treatments:

Rest

Neurostimulants (amantadine, ritalin,

etc)

Migraine Headache Neuro-Vascular (trigeminovascular system)

Genetic predisposition

Associated symptoms:

Visual (aura)

Photophobia/phonophobia

Ie, light/noise sensitivity

Dizziness

Nausea


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Migraine Management:

Education/Control

of Triggers

Medications:

Regular Sleep Schedule Caffeine Chocolate Stress reduction

Abortive: Preventative:

OTC:

Ibuprofin

Aleve

Excedrin migraine

etc.

Antidepressants:

SSRI’s

Tricyclics (eg,

amitriptyline,

imipramine)

Triptans:

zolmitriptan

sumatriptan (Imitrex)

rizatriptan (Maxalt)

Anticonvulsants:

valproic acid (Depakote)

gabapentin

topiramate (Topamax)

etc

Beta blockers

Calcium channel blockers

Medical Intervention – other areas:

Sleep Alterations

Sleep hygiene education

Medications: Trazodone, melatonin agonists,

nonbenzodiazepine hypnotics

Cognitive Issues

Neurostimulants*

amantadine, Ritalin, etc

Mood Disruption Psychotherapy

Antidepressants

SSRIs

Anxiolytics

SSRIs

benzodiazepines

*Non-FDA approved

Concussion Rehab??

PT MANAGEMENT IN

CONCUSSION

Vestibulo-Ocular Reflex Training

(Gaze Stability Training)

Maintain visual

fixation during head

movement

Direction of head

movement

Speed of head

movement

Posture

Target size

BPPV Canalith repositioning

maneuver

Incidence of BPPV in

Concussion may be

low (<5%) (Alsalaheen 2011)


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Sensory Integration Exercises &

Balance Training Oculomotor Training

Voluntary eye movements; Vergence eye movements

Training of Eye/Head Coordination Visual Motion Sensitivity training

Gradual exposure to

provocative stimuli

Light/Dark

Use of fixation point

Posture

Surface

Management of Cervicogenic Issues:

Cervical Spine Management Manual Therapy

Targeted strength training/ROM

Injection

Acupuncture (Michels 2007, Heikkilä 2000)

Surgery

Balance retraining

Cervical sensory retraining

Ocular motor retraining ( Revel 1994; Jull 2007; Kristjansson 2009)

Return to School following Concussion

Homebound instruction

Partial attendance

Late starts/Early dismissals

Rest periods during day

Extra time for assignment

completion

Excuse from non-essential

assignments

Postpone or stagger testing

Excuse from standardized

testing

Extra time and/or open book

testing

Exams in small/quiet rooms

Tutor

Excuse from gym & attending

sport practices

Excuse from assemblies,

band/orchestra, woodshop

Lunch in quiet area

Preferential classroom seating

Accommodations for

light/noise sensitivity

(earplugs, ball cap,

sunglasses, dimmer lights)

Books on tape

Audiotaped lectures

Provide note-taker or scribe

Provide classroom

notes/powerpoint prior to class

McGrath 2010

Mention also:

-

-

&/other state

programs


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Facilitating Safe Return to

Activity

PHYSICAL EXERTION AFTER

CONCUSSION application to the younger patient

Sean Learish, MPT

Centers for Rehab Services (CRS)

University of Pittsburgh Medical Center (UPMC)

Center for Sports Medicine

PURPOSE OF PRESENTATION

REVIEW RISKS OF RETURNING TO PHYSICAL EXERTION

AFTER CONCUSSION

REVIEW PRACTICAL APPROACHES TO PHYSICAL

EXAMINATION PRIOR TO RETURN TO PHYSICAL EXERTION

REVIEW 5 STAGE EXERTION PROTOCOL AND SCREENING

PROCESS FOR CONCUSSION PATIENTS

TO GIVE PRACTICAL IDEAS FOR A SAFE PROGRESSION OF

EXERCISES AFTER CONCUSSION

TO GIVE CLINICAL INSIGHTS AS IT RELATES TO PHYSICAL

EXERTION AFTER CONCUSSION IN ADOLESCENTS

Concussion Rehab at UPMC

UPMC Center for Sports

Medicine

UPMC Concussion Program

- Neuro-Cognitive testing

(ImPACT)

Exertion Based Program

CONCUSSION MANAGEMENT: Why?


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SERIOUS RISKS OF RETURN TO PLAY

Second Impact Syndrome (SIS) -adolescent at higher risk?

Post Concussion Syndrome (PCS) -adolescent at higher risk?

Chronic Traumatic Encephalopathy (CTE) -long term concern/ problem

Second Impact Syndrome (SIS)

Defined/described as “when an athlete sustains

an initial head injury and then suffers a second

head injury before the symptoms associated with

the first impact have cleared”

“second-impact dysautoregulation” vs. subdural

hematoma (SDH)

Similarities with non-accidental head trauma

(shaken-baby syndrome)

Questionable whether significant collision/impact

to head is necessary?

(Cantu and Gean)

Post Concussion Syndrome (PCS)

Defined (by World Health Organization): persistence of 3

or more of the following after head injury

headache, dizziness, fatigue, irritability, insomnia, concentration

difficulty, memory difficulty 4

Other physiological effects:

Heart and Autonomic Nervous system dysfunction

HR elevated and exaggerated sympathetic responses 5,6,7,8

Cerebral Blood Flow

auto-regulation disrupted9

Chronic Traumatic Encephalopathy (CTE)

Defined: a progressive degenerative disease of the brain found in

athletes (and others) with a history of repetitive brain trauma,

including symptomatic concussions as well as asymptomatic sub-

concussive hits to the head. (AKA : Dementia pugilistica)

Degeneration of the brain tissue, build-up of an abnormal protein

called tau.

Clinical symptoms : memory loss, confusion, impaired judgment,

impulse control problems, aggression, depression, and, eventually,

progressive dementia.

McKee, et al1 and Guskiewicz, et al 3

Management Following Concussion

Typical Management

On Field Management

Acute Management

Sub-Acute (2-3 wks)

Chronic/ PCS (>6wks)

International Conference on

Concussion in Sport

RECOMMENDATIONS

Persistent symptoms/ PCS

Leddy, et al: sub-symptom threshold

exercise training (SSTET)

Exertion Testing

1. Testing vs. Rehab

Progressive

Incorporate vestibular challenges

2. When Symptom Free

Testing for RTP decision

Testing for clearance of activity

3. If Symptomatic

Test for symptom exacerbation

Establish thresholds

Consultation


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GRADED REHAB PROGRAM

Sub-Symptom Threshhold Exercise Training (SSTET)

Leddy, et al

Traditional Target Heart Rate approach

Karvonen’s Formula with gradual progression

{(220-Age) – Resting H.R.} X Target % + Resting H.R

Comprehensive Program

Graded approach

Integrate vestibular challenges

Individualized

Target Heart Rate: 5 Stage Approach

1. Minimal Exertion: Target heart rate 30-40%

2. Light-Moderate Exertion: Target heart rate 40–60%

3. Moderately Aggressive: Target heart rate 60–80%

4. Sports Performance: Target heart rate 80-90%

5. Sports Performance: Full Exertion with contact

Stages 1-4: Physical Therapy

Stage 5: Sports Performance

Exertion Based Rehab: 5 Stages

Stages 1-4: Physical Therapy

Graded progression of physical exertion

Integrates cardiovascular, strength, dynamic balance,

and functional/sport specific training

Stages 5: Sports Performance

More aggressive exertion exercise including sport

specific performance training

Evaluation History

- Current and previous history

- Review Neuro-cognitive info

(ImPACT data)

- Headache/migraine history

- Goals and expectations

- Current Symptoms

- Medications

- Daily concussion data

*** very important ***

Symptoms (0-6) Pre Post

Headaches (Head

Pressure)

Nausea

Dizziness

Fatigue

Feel "Slowed Down"

Feeling "Mentally Foggy"

Evaluation (cont.)

Vitals -BP, Resting Heart Rate

Cervical Screen -ROM, strength, special testing

Musculoskeletal Screen -ROM, strength

Balance/Vestibular Screen - BESS test

Exertion Test - GRADUATED TREADMILL TEST (SSTET)

Conditioning tests - FIT test, 6 minute Walk test

STAGE 1 Minimal Exertion

POPULATION: symptomatic, chronic problem, or very acute injury.

EXERTION : 30-40 % of MAX

-10-15 minutes

-Low Impact: Bike, Upper Body Ergometer, Treadmill (walk)

THERAPEUTIC EXERCISE -Light stretching

-Light strengthening

BALANCE -Low Level Tasks

-Romberg Activities

*Specialized Balance/Vestibular treatment (as appropriate)


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STAGE 1 : Exertion Activities STAGE 2 (Light-Moderate Exertion)

POPULATION: less symptomatic, finding threshold for exercise, or acute injury attempting to progress.

EXERTION : 40-60 % of max

-20-25 minutes

-Low Impact: Elliptical, Treadmill (incline),

step exercise

THERAPEUTIC EXERCISE -Some active stretching

-Moderate strength exercise

BALANCE -Moderate level tasks

-Work on movement and position changes

-Swiss Ball, VOR activities, Ball tossing

STAGE 2 : Exertion Activities STAGE 3 (Moderately Aggressive Exertion)

POPULATION: mildly symptomatic, chronic patient attempting to progress, or acute injury attempting return to normal range of exercise.

EXERTION: 60-80 % of MAX

-25-30 minutes

-Impact activities: jogging, agility

THERAPEUTIC EXERCISE -Active stretching, more aggressive

strength exercise

-Training exercise with position change &

head movement

-Integrate cognitive challenges (concentration)

BALANCE -Dynamic Balance tasks

-Integrate exertion, strength, and dynamic balance activities

STAGE 3 : Exertion Activities STAGE 4 (Functional Training)

POPULATION: no symptoms or infrequent/episodic symptoms only, patient attempting to resume specific activities, functional training phase.

EXERTION : 80 % of MAX

-40-50 minutes -aggressive cardio, including intervals

THERAPEUTIC EXERCISE -Dynamic stretching and other activities

to maintain consistent elevation of heart rate

-Training exercise with position change and head movement

BALANCE -Dynamic Balance tasks -Integrate exertion and vestibular rehab

into work or sport specific activities


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STAGE 4 : Functional Exertion Activities STAGE 5 (Sports Performance Training)

POPULATION: symptom free, individuals attempting to return to competitive sports

EXERTION : 80-100 % of MAX

-Sport specific endurance activities

-Interval training

EXERCISE -Aggressive sport specific

flexibility and strength training

BALANCE -Aggressive sport specific

dynamic balance activities

* prepares for practice and game intensity

Dynamic Balance Exercises Subjective and Objective Assessment

1. Data Before Exertion

a) Symptoms reports

b) Vitals (heart rate, BP)

c) Medication confirmation

d) Assessment of activities prior to

exertion

e) Balance check (modified BESS)

2. Data After Exertion

a) Symptom reports

b) Vitals

c) Balance check (modified BESS)

CRITERIA FOR PROGRESSION OF STAGES :

1. No exacerbation of symptoms with all activities (Cardio, Therapeutic Exercise, and Balance).

2. Post exertion data/testing normal.

3. If baseline symptoms persist prior to exercise, need to report no exacerbation of symptoms for multiple treatments

4. Patient and patients family need to express a clear desire and comfort level with plans to progress.

5. Need to be certain that patient is being honest about reporting of symptoms.

Rate of Progression

Variable

- according to history and symptoms

- according to type of activity / exercise

- age

Dependent on patient’s goals

- in season of sport

- time line for return

Dependent on response to exercise

- increase, decrease, no change


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Physical Exertion: Variables of Interest

Activity Level prior to rehab session (cognitive/physical)

Maximum Heart Rate and/or Sustained Heart Rate

Symptoms severity and symptom exacerbation

Medications

Sensitivity to head movement and position change (vestibular)

Age- Adolescent at more risk?

COMPONENTS of EXERTION

Therapeutic Exercise (Cardio, Strength, Flexibility)

Dynamic Balance Activities (proprioception, vestibular)

Cognitive (Concentration, focus)

KEY POINTS OF CLINICAL OBSERVATION

Graded return to exertion

Individualized care with Multi-Discipline

involvement

Patient/ Family Education

ULTIMATE GOAL: Compliment Neuro-

Cognitive and Medical Management

Safe Return to physical activities/sport

Unique factors of adolescent patients

Parental involvement

Behavioral factors

More conservative approach

Effects of Exertion Rehab Program

POSITIVE :

Physiologic effect of SSTET on brain (autonomic

balance and cerebral autoregulation?)

Structure allows return to activity safely…

potentially quicker

Education of patient/family

Avoid deconditioning and depression

NEGATIVE:

challenges of limited access/ supervision

exacerbation of concussion symptoms

Adolescent Case

Presentation


Adolescent Athlete

2/10/12





HPI 15 yo male

9/17/11 – helmet to helmet blow during football

game

No LOC; immediately dazed, neck pain, blurred

vision, photophobia

Removed from game; taken to Children’s

Hospital ED

C-Spine Radiographs Neg

3 hrs retrograde amnesia; 30 min post-traumatic

amnesia

PMH Prior Concussions:

Aug 2011 – concussion during football

practice (sx’s: HA’s, dizziness, phonophobia,

bradyphrenia) Managed by ATC; returned to

play 1 wk later

8th grade

Social/Academic:

Entering 10th grade; Average/above average

student; Plays football, baseball; skiier

Parents divorced; father lives in Florida

INSERT

BRET’S

Presenting Sx’s - 1 wk post injury:

• Attending school ½ days; no other exertion

• HA’s 8-10 daily

• Phono/photo sensitivity

• Dizziness

• Blurred Vision

• Fogginess

• Fatigue

• Near-syncope w/ sit-stand (2x)

• Memory difficulty

Neurocognitive Data (ImPACT™)

9/23/10 Pre-Season

Baseline

Verbal Memory

Composite 37 (< 1%) 83 (53%)

Visual Memory

Composite 32 (< 1%)

96 (98%)

Visual Motor

Speed

Composite

20.45 (< 1%)

36.55 (52%)

Reaction Time

Composite 1.20 (< 1%)

0.6 (51%)

Symptom Score

(range 0-138)

73 1

Initial Interventions:

Recommend removed from school

MRI/MRA of brain (neg)

F/U 2 wks

F/U Visit – 4 wks post injury

Attending school ½ days

HA’s continue; worse @ end of school. Aggravated by

environments with lot of sound and stimulation

+ Mental fogginess, trouble concentrating, difficulty

focusing, and difficulty with short term memory.

+ Dizziness and impaired balance

Interventions:

Placed on amantadine (neurostimulant)

Referred to Vestibular PT


Adolescent Athlete

2/10/12





Vestibular PT Eval – 5 wks post injury

Constant HA’s (2-9/10)

worse w/ reading, riding in car/motion, noise, bright lights, busy environments

Dizziness

Near syncopal episodes w/ sit-stand

Quick head movements

Riding in car

Poor balance

Sleep dysregulation – initiating

Fatigue

Irritability

Neck pain- resolved

Vestibular PT Referral:

Impaired Postural Control:

mCTSIB – increased sway with eyes open and

closed on compliant foam

Ocular motor: slowed saccades, abnormal

convergence

Blurry/dizzy w/ slow VOR

Initial Vestibular PT Data

10/27/11

ABC 77%

DHI 58/100

DGI 21/24

FGA 25/30

Vestibular PT Interventions:

Home based ex: (1-2x/day)

Ocular Motor training: versions (saccades &

vergence

Gaze stability training

Balance training: sensory organization and

dynamic ex

Clinic program 1x/wk

8 Week f/u: Neurocognitive Data (ImPACT)

9/23/11 11/10/11

Verbal Memory

Composite 37 (< 1%) 61 (2%)

Visual Memory

Composite 32 (< 1%) 45 (<1%)

Visual Motor Speed

Composite 20.45 (< 1%) 26.1 (3%)

Reaction Time

Composite 1.20 (< 1%) 1.06 (<1%)

Symptom Score 73 18

Management – 8 wk f/u

Removed from school; homebound

instruction 1hr/day, 5d/wk

Instructed to take amantadine as prescribed

2x/day

Initiate amitriptyline

Continue Vestibular PT 1x/wk

Initiated VisionTherapy


Adolescent Athlete

2/10/12





Vestibular PT Data 10/27/11 12/1/11

ABC 77% 98%

DHI 58/100 28/100

Ocular Motor Convergence

insufficiency, slowed

saccades

Saccades WNL; mild

convergence

insufficiency (started

vision therapy)

mCTSIB ↑’d sway on foam w/

eyes open & closed

WNL all conditions w/

head turns

DGI 21/24 24/24

FGA 25/30 30/30

DVA 3 line loss with

clinical exam; severe

sx’s

Less symptomatic

Neurocognitive Data (ImPACT™)

9/23/11 11/10/11 12/01/11

Verbal Memory

Composite

37 (< 1%) 61 (2%) 67 (5%)

Visual Memory

Composite

32 (< 1%) 45 (<1%) 82 (72%)

Visual Motor

Speed

Composite

20.45 (< 1%) 26.1 (3%) 42.55 (85%)

Reaction Time

Composite

1.20 (< 1%) 1.06 (<1%) 0.67 (25%)

Symptom

Score

73 18 21

12/1/11 –

Improving

Continue homebound education thru end of

calendar year

Continue amantadine & amitriptyline

12/8/11

Referred for Exertional PT

12/22/11

D/C from Vestibular PT

Exertional PT Evaluation: Patient History

Evaluation

Symptoms

Deficits

Exertional Training:

Established threshold

Graded program

Symptom reporting

Mild symptom exacerbation

Factors Influencing Outcome

Age

Prior concussion ?

Amnesia

Cluster of sx’s combined w/ early

neurocognitive data


Adolescent Athlete

2/10/12





Questions?

Exertional References

1. McKee, AC, Cantu, RC, et al. Chronic Traumatic Encephalopathy in Athletes: Progressive Tauopathy

After Repetitive Head Injury. J Neuropathol Exp Neurol. Vol. 68, No. 7 July 2009 pp. 709Y735

2. Cantu RC, Gean AD. Second-Impact and a Small Subdural Hematoma. Journal of Neurotrauma 27:

1557-1564.

3. Guskiewicz KM, Marshall SW, Bailes J, McCrea M, Harding HP, Matthews A, Mihalik JR, Cantu RC:

Recurrent Concussion and Risk of Depression in Retired Professional Football Players. Med Sci

Sports Exerc 39:903-909, 2007.

4. Boake C, McCauley SR, Levin HS, et al. Diagnostic criteria for postconcussional syndrome after mild

to moderate traumatic brain injury. J Neuropsychiatry Clin Neuroscience. 2005;17:350-356.

5. Gall B, Parkhouse W, Goodmand D. Heart rate variability of recently concussed athletes at rest and

exercie. Med Sci Sports Exercise. 2004;36:1269-1274.

6. Hanna-Pladdy B, Berry ZM, Bennett T, et al. Stress as a diagnostic challenge for postconcussive

symptoms: sequelae of mild traumatic brain injury or physiological stress response. Clin

Neuropsychol. 2001; 15: 289-304.

7. King ML, Lichtman SW, Seliger G, et al. Heart rate variability in chronic traumatice brain injury. Brain

Inj. 1997;11:445-453.

8. Gall B, Parkhouse WS, Goodman D. Exercise following a sport induced concusssion. Br Journal of

Sports Med. 2004;38:773-777.

9. DeWitt DS, Prough DS. Traumatic cerebral vascular injury: the effects of concussive brain injury on the

cerebral vasculature. J Neurotrauma. 2003; 20:795-825

10. McCrory P, Johnston K, Meeuwisse W, et al. Summary and agreement statement o fthe 2nd

International Conference on Concussion n Sport, Prague 2004, Clin J Sports Med. 2005; 15:48-55.

11. McCrory P, Meeuwisse W, Johnston K, et al. Concsensus statement on concussion in sport, 3rd

International Conference in Sport, Zurich, 2008. Clin J Sports Med. 2009;19:185-200.

12. Leddy JJ et al. A Preliminary Study of Subsymptom Threshold Exercise Training for Refractory Post

Concussion Syndrome. Clin J Sport Med. Vol 20: 1 (Jan 2010).

References: Concussion Management in the Adolescent Athlete

1. Alsalaheen BA, Mucha A, Morris LO, et al. Vestibular Rehabilitation for Dizziness and Balance Disorders After Concussion. Journal of Neurologic Physical Therapy. 2010;34:87-93. 2. Aubry M, Cantu R, Dvorak J, et al. Summary and agreement statement of the First International Conference on Concussion in Sport, Vienna 2001. Recommendations for the improvement of safety and health of athletes who may suffer concussive injuries. Br J Sports Med. Feb 2002;36(1):6-10. 3. Bakhos LL, Lockhart GR, Myers R, Linakis JG. Emergency department visits for concussion in young child athletes. Pediatrics. Sep 2010;126(3):e550-556. 4. Bigal ME, Rapoport AM, Sheftell FD, Tepper SJ, Lipton RB. Transformed migraine and medication overuse in a tertiary headache centre--clinical characteristics and treatment outcomes. Cephalalgia. Jun 2004;24(6):483-490. 5. Broshek DK, Kaushik T, Freeman JR, Erlanger D, Webbe F, Barth JT. Sex differences in outcome following sports-related concussion. J Neurosurg. May 2005;102(5):856-863. 6. Browne GJ, Lam LT. Concussive head injury in children and adolescents related to sports and other leisure physical activities. Br J Sports Med. Feb 2006;40(2):163-168. 7. Ciuffreda KJ, Kapoor N, Rutner D, Suchoff IB, Han ME, Craig S. Occurrence of oculomotor dysfunctions in acquired brain injury: a retrospective analysis. Optometry. Apr 2007;78(4):155-161. 8. Ciuffreda KJ, Rutner D, Kapoor N, Suchoff IB, Craig S, Han ME. Vision therapy for oculomotor dysfunctions in acquired brain injury: a retrospective analysis. Optometry. Jan 2008;79(1):18-22. 9. Collins M, Lovell MR, Iverson GL, Ide T, Maroon J. Examining concussion rates and return to play in high school football players wearing newer helmet technology: a three-year prospective cohort study. Neurosurgery. Feb 2006;58(2):275-286; discussion 275-286. 10. Collins MW, Grindel SH, Lovell MR, et al. Relationship between concussion and neuropsychological performance in college football players. Jama. Sep 8 1999;282(10):964-970. 11. Collins MW, Iverson GL, Lovell MR, McKeag DB, Norwig J, Maroon J. On-field predictors of neuropsychological and symptom deficit following sports-related concussion. Clin J Sport Med. Jul 2003;13(4):222-229. 12. Collins MW, Lovell MR, Iverson GL, Cantu RC, Maroon JC, Field M. Cumulative effects of concussion in high school athletes. Neurosurgery. Nov 2002;51(5):1175-1179; discussion 1180-1171. 13. Covassin T, Elbin RJ. The female athlete: the role of gender in the assessment and management of sport-related concussion. Clin Sports Med. Jan 2011;30(1):125-131, x. 14. Dischinger PC, Ryb GE, Kufera JA, Auman KM. Early predictors of postconcussive syndrome in a population of trauma patients with mild traumatic brain injury. J Trauma. Feb 2009;66(2):289-296; discussion 296-287. 15. Furman J, Cass S, Whitney S. Vestibular disorders: a case-study approach. 3rd ed. New York, NY: Oxford University Press; 2010.

16. Gessel LM, Fields SK, Collins CL, Dick RW, Comstock RD. Concussions among United States high school and collegiate athletes. J Athl Train. Oct-Dec 2007;42(4):495-503. 17. Geurts AC, Ribbers GM, Knoop JA, van Limbeek J. Identification of static and dynamic postural instability following traumatic brain injury. Arch Phys Med Rehabil. Jul 1996;77(7):639-644. 18. Gioia GA, Collins M, Isquith PK. Improving identification and diagnosis of mild traumatic brain injury with evidence: psychometric support for the acute concussion evaluation. J Head Trauma Rehabil. Jul-Aug 2008;23(4):230-242. 19. Gioia GA, Schneider JC, Vaughan CG, Isquith PK. Which symptom assessments and approaches are uniquely appropriate for paediatric concussion? Br J Sports Med. May 2009;43 Suppl 1:i13-22. 20. Gioia GAJ, J; Isquith, P. Psychometric properties of the parent and teacher post-concussion symptom inventory (PCSI) for children and adolescents. J Int Neuropsych Soc. 2008;14 (Suppl 1):204. 21. Giza CC, Hovda DA. The Neurometabolic Cascade of Concussion. J Athl Train. Sep 2001;36(3):228-235. 22. Griffiths MV. The incidence of auditory and vestibular concussion following minor head injury. J Laryngol Otol. Mar 1979;93(3):253-265. 23. Guskiewicz KM. Postural stability assessment following concussion: one piece of the puzzle. Clin J Sport Med. Jul 2001;11(3):182-189. 24. Guskiewicz KM, McCrea M, Marshall SW, et al. Cumulative effects associated with recurrent concussion in collegiate football players: the NCAA Concussion Study. Jama. Nov 19 2003;290(19):2549-2555. 25. Guskiewicz KM, Riemann BL, Perrin DH, Nashner LM. Alternative approaches to the assessment of mild head injury in athletes. Med Sci Sports Exerc. Jul 1997;29(7 Suppl):S213-221. 26. Guskiewicz KM, Valovich McLeod TC. Pediatric sports-related concussion. Pm R. Apr 2011;3(4):353-364; quiz 364. 27. Guskiewicz KM, Weaver NL, Padua DA, Garrett WE, Jr. Epidemiology of concussion in collegiate and high school football players. Am J Sports Med. Sep-Oct 2000;28(5):643-650. 28. Heikkila H, Johansson M, Wenngren BI. Effects of acupuncture, cervical manipulation and NSAID therapy on dizziness and impaired head repositioning of suspected cervical origin: a pilot study. Man Ther. Aug 2000;5(3):151-157. 29. Hoffer ME, Balaban C, Gottshall K, Balough BJ, Maddox MR, Penta JR. Blast exposure: vestibular consequences and associated characteristics. Otol Neurotol. Feb 2010;31(2):232-236. 30. Iverson G. Predicting slow recovery from sport-related concussion: the new simple-complex distinction. Clin J Sport Med. Jan 2007;17(1):31-37. 31. Iverson GL, Gaetz M, Lovell MR, Collins MW. Relation between subjective fogginess and neuropsychological testing following concussion. J Int Neuropsychol Soc. Oct 2004;10(6):904-906. 32. Iverson GL, Gaetz M, Lovell MR, Collins MW. Cumulative effects of concussion in amateur athletes. Brain Inj. May 2004;18(5):433-443.

33. Jacobson GP, Newman CW. The development of the Dizziness Handicap Inventory. Arch Otolaryngol Head Neck Surg. Apr 1990;116(4):424-427. 34. Jull G, Falla D, Treleaven J, Hodges P, Vicenzino B. Retraining cervical joint position sense: the effect of two exercise regimes. J Orthop Res. Mar 2007;25(3):404-412. 35. Kapoor N, Ciuffreda KJ. Vision Disturbances Following Traumatic Brain Injury. Curr Treat Options Neurol. Jul 2002;4(4):271-280. 36. King NS, Crawford S, Wenden FJ, Moss NE, Wade DT. The Rivermead Post Concussion Symptoms Questionnaire: a measure of symptoms commonly experienced after head injury and its reliability. J Neurol. Sep 1995;242(9):587-592. 37. Kisilevski V, Podoshin L, Ben-David J, et al. Results of otovestibular tests in mild head injuries. Int Tinnitus J. 2001;7(2):118-121. 38. Klig JE, Kaplan CP. Minor head injury in children. Curr Opin Pediatr. Jun 2010;22(3):257-261. 39. Kristjansson E, Treleaven J. Sensorimotor function and dizziness in neck pain: implications for assessment and management. J Orthop Sports Phys Ther. May 2009;39(5):364-377. 40. Lau B, Lovell MR, Collins MW, Pardini J. Neurocognitive and symptom predictors of recovery in high school athletes. Clin J Sport Med. May 2009;19(3):216-221. 41. Lau BC, Collins MW, Lovell MR. Sensitivity and specificity of subacute computerized neurocognitive testing and symptom evaluation in predicting outcomes after sports-related concussion. Am J Sports Med. Jun 2011;39(6):1209-1216. 42. Lau BC, Kontos AP, Collins MW, Mucha A, Lovell MR. Which On-field Signs/Symptoms Predict Protracted Recovery From Sport-Related Concussion Among High School Football Players? Am J Sports Med. Jun 28 2011. 43. Leddy JJ, Kozlowski K, Donnelly JP, Pendergast DR, Epstein LH, Willer B. A preliminary study of subsymptom threshold exercise training for refractory post-concussion syndrome. Clin J Sport Med. Jan 2010;20(1):21-27. 44. Leddy JJ, Kozlowski K, Fung M, Pendergast DR, Willer B. Regulatory and autoregulatory physiological dysfunction as a primary characteristic of post concussion syndrome: implications for treatment. NeuroRehabilitation. 2007;22(3):199-205. 45. Lincoln AE, Caswell SV, Almquist JL, Dunn RE, Norris JB, Hinton RY. Trends in concussion incidence in high school sports: a prospective 11-year study. Am J Sports Med. May 2011;39(5):958-963. 46. Lovell M, Collins M, Bradley J. Return to play following sports-related concussion. Clin Sports Med. Jul 2004;23(3):421-441, ix. 47. Lovell MR, Iverson GL, Collins MW, et al. Measurement of symptoms following sports-related concussion: reliability and normative data for the post-concussion scale. Appl Neuropsychol. 2006;13(3):166-174. 48. Majerske CW, Mihalik JP, Ren D, et al. Concussion in sports: postconcussive activity levels, symptoms, and neurocognitive performance. J Athl Train. May-Jun 2008;43(3):265-274. 49. Maskell F, Chiarelli P, Isles R. Dizziness after traumatic brain injury: overview and measurement in the clinical setting. Brain Inj. Mar 2006;20(3):293-305. 50. Maskell F, Chiarelli P, Isles R. Dizziness after traumatic brain injury: results from an interview study. Brain Inj. Jun 2007;21(7):741-752.

51. Masson F, Maurette P, Salmi LR, et al. Prevalence of impairments 5 years after a head injury, and their relationship with disabilities and outcome. Brain Inj. Jul 1996;10(7):487-497. 52. Maugans TA, Farley C, Altaye M, Leach J, Cecil KM. Pediatric Sports-Related Concussion Produces Cerebral Blood Flow Alterations. Pediatrics. Nov 30 2011. 53. McCrea M, Hammeke T, Olsen G, Leo P, Guskiewicz K. Unreported concussion in high school football players: implications for prevention. Clin J Sport Med. Jan 2004;14(1):13-17. 54. McCrory P, Johnston K, Meeuwisse W, et al. Summary and agreement statement of the 2nd International Conference on Concussion in Sport, Prague 2004. Clin J Sport Med. Mar 2005;15(2):48-55. 55. McCrory P, Meeuwisse W, Johnston K, et al. Consensus statement on Concussion in Sport 3rd International Conference on Concussion in Sport held in Zurich, November 2008. Clin J Sport Med. May 2009;19(3):185-200. 56. McGrath N. Supporting the student-athlete's return to the classroom after a sport-related concussion. J Athl Train. Sep-Oct 2010;45(5):492-498. 57. Meehan WP, 3rd, Mannix R. Pediatric concussions in United States emergency departments in the years 2002 to 2006. J Pediatr. Dec 2010;157(6):889-893. 58. Michels T, Lehmann N, Moebus S. Cervical vertigo--cervical pain: an alternative and efficient treatment. J Altern Complement Med. Jun 2007;13(5):513-518. 59. Mihalik JP, Stump JE, Collins MW, Lovell MR, Field M, Maroon JC. Posttraumatic migraine characteristics in athletes following sports-related concussion. J Neurosurg. May 2005;102(5):850-855. 60. Morrison WE, Arbelaez JJ, Fackler JC, De Maio A, Paidas CN. Gender and age effects on outcome after pediatric traumatic brain injury. Pediatr Crit Care Med. Mar 2004;5(2):145-151. 61. Peterson CLPATC, Ferrara MSPATC, Mrazik MP, Piland SMAATC, Elliott RMD. Evaluation of Neuropsychological Domain Scores and Postural Stability Following Cerebral Concussion in Sports. [Article]. Clinical Journal of Sport Medicine July 2003;13(4):230-237. 2003. 62. Prins ML, Hales A, Reger M, Giza CC, Hovda DA. Repeat traumatic brain injury in the juvenile rat is associated with increased axonal injury and cognitive impairments. Dev Neurosci. 2010;32(5-6):510-518. 63. Randolph C, McCrea M, Barr WB. Is neuropsychological testing useful in the management of sport-related concussion? J Athl Train. Jul-Sep 2005;40(3):139-152. 64. Revel M, Minguet M, Gregoy P, Vaillant J, Manuel JL. Changes in cervicocephalic kinesthesia after a proprioceptive rehabilitation program in patients with neck pain: a randomized controlled study. Arch Phys Med Rehabil. Aug 1994;75(8):895-899. 65. Shumway-Cook A, Horak FB. Assessing the influence of sensory interaction of balance. Suggestion from the field. Phys Ther. Oct 1986;66(10):1548-1550. 66. Terrio H, Brenner LA, Ivins BJ, et al. Traumatic brain injury screening: preliminary findings in a US Army Brigade Combat Team. J Head Trauma Rehabil. Jan-Feb 2009;24(1):14-23.

67. Williamson IJ, Goodman D. Converging evidence for the under-reporting of

concussions in youth ice hockey. Br J Sports Med. Feb 2006;40(2):128-132; discussion

128-132.

Documents

CONCUSSION Objectives MANAGEMENT IN THE ADOLESCENT ATHLETE · Neuro-Opthalmology /Optometry Psychology/Psychiatry Cognitive Therapy . Concussion Management in the Adolescent Athlete